Physician Reviewer II

TMF Health Quality Institute; Austin (TX); Remote; USD 160,000 - 200,000; Full time

Job summary

A leading healthcare quality organization seeks a Physician Reviewer to conduct comprehensive reviews of Medicare appeals, contributing specialized medical knowledge. Responsibilities include preparing for hearings, making independent decisions, and ensuring compliance with regulations. Ideal candidates will have significant experience in patient care and relevant medical qualifications, with a strong focus on independent judgment and regulatory understanding.

Benefits

Medical, dental, and vision insurance

401K

Tuition Reimbursement

Short and long-term disability insurance

Qualifications

• Minimum of 7 years clinical or direct patient care experience.
• Active State license to practice medicine and Board certification required.
• No federal or state sanctions related to practice.

Responsibilities

• Reviews appeals brought by Medicare beneficiaries and makes independent decisions.
• Provides testimony in Administrative Law Judge hearings as necessary.
• Plans and prepares defense strategies for appeals.

Skills

Medical evidence evaluation

Regulatory knowledge

Independent judgment

Education

Doctor of Medicine or Doctor of Osteopathic Medicine

Job description

Please make sure your application is complete, including your education, employment history, and any other applicable sections. Initial screening is based on the minimum requirements as defined in the job posting, such as education, experience, licenses, and certifications. Your experience should also address the knowledge, skills and abilities needed for the role. Incomplete applications will not be considered.

• This position is located Remote Anywhere US

Position Purpose :

Performs highly advanced (senior-level) work. Reviews appeals brought by Medicare beneficiaries, suppliers and providers of adverse coverage decisions. Reaches independent conclusions based on the available documentation and facts, relevant laws, and Medicare regulations and guidelines. Provides testimony in Administrative Law Judge (ALJ) hearings as a party witness to clarify factual and / or policy issues in the case. Works under minimal supervision, with considerable latitude for the use of initiative and independent judgement.

• Plans, prepares for and participates in ALJ hearings by providing written position papers, oral support or testimony as required.
• Plans and reviews cases to determine the appropriate defense.
• Plans, prepares for, and defends a reconsideration decision by presenting at the ALJ hearing by telephone.
• Plans and provides medical support to the ALJ team.
• Plans and writes a reconsideration decision that is clear and supports the determination made.
• Makes sound, independent decisions based on medical evidence in accordance with statutes, regulation, rulings, Centers for Medicare & Medicaid Services (CMS) policy, and local Medicare policy, or other authoritative sources.
• Plans and ensures that all appeal issues raised by the beneficiary, representative, and supplier have been addressed.

Minimum Qualifications

Education

• Doctor of Medicine or Doctor of Osteopathic Medicine degree from an accredited Medical School

License and Certification

• Active State license to practice medicine
• Board certification

Experience

• Seven (7) years of clinical or direct patient care
• No federal or state sanctions as would appear on reporting from the National Practitioner Data Bank (NPDB)
• Currently have or have had direct patient care within the last three years
• Medicare Policies and Procedures, preferred

C2C offers an excellent benefits package, including :

• Medical, dental, vision, life, accidental death and dismemberment, and short and long-term disability insurance
• Section 125 plan
• 401K
• Tuition Reimbursement

EOE Vet / Disability

Equal Opportunity Employer / Protected Veterans / Individuals with Disabilities

This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights notice from the Department of Labor.

Create a job alert for this search

Physician Reviewer • Austin, TX, United States